Current through all regulations passed and filed through September 16, 2024
(A) HPP:
Unless an MCO has negotiated a different payment rate with a
hospital pursuant to rule
4123-6-10 of the Administrative
Code, reimbursement for hospital outpatient services with a date of service of
May 1, 2024 or after will be the applicable rate set forth in
this rule as follows:
(1) Except as
otherwise provided in this rule, reimbursement for hospital outpatient services
will be equal to the applicable medicare reimbursement rate for the hospital
outpatient service under the medicare outpatient prospective payment system as
implemented by the materials specified in paragraph (A)(10) of this rule,
multiplied by a bureau-specific payment adjustment factor, which will be
2.758
for children's hospitals and 1.485 for all hospitals other than children's
hospitals, plus the add-on payments set forth in paragraph (A)(4) of this rule,
if applicable.
BWC will use the medicare integrated outpatient code editor and
medicare medically unlikely edits in effect as implemented by the materials
specified in paragraph (A)(9) of this rule and table 8 of the appendix to this
rule to process bills for hospital outpatient services under this rule;
however, BWC will not apply the outpatient code edits identified in table 1 of
the appendix to this rule.
BWC will not apply the annual medicare outpatient prospective
payment system outlier, hold harmless, and exempt cancer hospital
reconciliation processes to payments for hospital outpatient services under
this rule.
For purposes of this rule, hospitals are identified as critical
access hospitals, rural sole community hospitals, essential access community
hospitals and exempt cancer hospitals based on the hospitals' designation in
the medicare outpatient provider specific file in effect implemented by the
materials specified in paragraph (A)(10) of this rule.
For purposes of this rule, the following hospitals are
recognized as "children's hospitals": nationwide children's hospital
(Columbus), Cincinnati children's hospital medical center, shriners hospital
for children (Cincinnati), university hospitals rainbow babies and children's
hospital (Cleveland), Toledo children's hospital, children's hospital medical
center of Akron, and children's medical center of Dayton.
Reimbursement for any hospital outpatient services identified
in table 6 of the appendix to this rule will be determined using the medicare
outpatient prospective payment system methodology as set forth in this
paragraph, applying the status indicator and ambulatory payment classification
specified for the service in table 6 of the appendix to this rule.
In the event the centers for medicare and medicaid services
makes subsequent adjustments to the medicare reimbursement rates under the
medicare outpatient prospective payment system as implemented by the materials
specified in paragraph (A)(10) of this rule, other than technical corrections,
including but not limited to adjustments related to federal budget
sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239,
2 U.S.C.
900 to
907(d) as amended
as of the effective date of this rule, the "applicable medicare reimbursement
rate for the hospital outpatient service under the medicare outpatient
prospective payment system" as specified in this paragraph will be determined
by the bureau without regard to such subsequent adjustments.
(2) Services reimbursed via fee schedule.
These services will not be wage index adjusted.
(a) Services reimbursed via fee schedule to
which the bureau-specific payment adjustment factor will be applied.
Except as otherwise provided in paragraphs (A)(2)(b)(ii) and
(A)(2)(b)(iii) of this rule, hospital outpatient services reimbursed via fee
schedule under the medicare outpatient prospective payment system will be
reimbursed under the applicable medicare fee schedule in effect as implemented
by the materials specified in paragraph (A)(10) of this rule, plus the add-on
payments set forth in paragraph (A)(4) of this rule, if applicable.
(b) Services reimbursed via fee
schedule to which the bureau-specific payment adjustment factor will not be
applied.
The following services will be reimbursed the lesser of the
charges billed by the hospital for the allowed services rendered, the
applicable fee schedule rates set forth in tables 2, 3, 4 and 5 of the appendix
to this rule, or the rate the MCO contracted or negotiated with the
hospital:
(i) Hospital outpatient
vocational rehabilitation services for which the bureau has established a fee
as set forth in table 2 of the appendix to this rule.
(ii) Hospital outpatient services reimbursed
via fee schedule under the medicare outpatient prospective payment system that
the bureau has determined will be reimbursed at a rate other than the
applicable medicare fee schedule in effect as implemented by the materials
specified in paragraph (A)(10) of this rule, for which the bureau has
established a fee as set forth in table 3 of the appendix to this
rule.
(iii) Hospital outpatient
services not reimbursed under the medicare outpatient prospective payment
system that the bureau has determined are necessary for treatment of injured
workers, for which the bureau has established a fee as set forth in tables 4
and 5 of the appendix to this rule.
(3) Services reimbursed at reasonable cost.
To calculate reasonable cost, the line item charge will be multiplied by the
hospital's outpatient cost to charge ratio from the medicare outpatient
provider specific file in effect as implemented by the materials specified in
paragraph (A)(10) of this rule. These services will not be wage index adjusted.
(a) Services reimbursed at reasonable cost to
which the bureau-specific payment adjustment factor will be applied.
Notwithstanding any other reimbursement methodology set forth
in this rule, critical access hospitals will be reimbursed at one hundred one
per cent of reasonable cost for all payable line items.
(b) Services reimbursed at reasonable cost to
which the bureau-specific payment adjustment factor will not be applied.
(i) Services designated as inpatient only
under the medicare outpatient prospective payment system.
(ii) Hospital outpatient services reimbursed
at reasonable cost as identified in tables 3 and 4 of the appendix to this
rule.
(4)
Add-on payments calculated using the applicable medicare outpatient prospective
payment system methodology and formula in effect as implemented by the
materials specified in paragraph (A)(10) of this rule. These add-on payments
will be applied after the application of the bureau-specific payment adjustment
factor.
(a) Outlier add-on payment. An
outlier add-on payment will be provided on a line item basis for partial
hospitalization services and for ambulatory payment classification reimbursed
services for all hospitals other than critical access hospitals.
(b) Rural hospital add-on payment. A rural
hospital add-on payment will be provided on a line item basis for rural sole
community hospitals, including essential access community hospitals; however,
drugs, biological, devices reimbursed via pass-through and reasonable cost
items will be excluded. The rural add-on payment will be calculated prior to
the outlier add-on payment calculation.
(c) Hold harmless add-on payment. A hold
harmless add-on payment will be provided on a line item basis to exempt cancer
centers and children's hospitals. The hold harmless add-on payment will be
calculated after the outlier add-on payment calculation.
(5) Providers not participating in the
medicare program.
Reimbursement for outpatient services provided by hospitals and
distinct-part units of hospitals that do not participate in the medicare
program will be calculated in accordance with the methodologies set forth in
this rule, using the applicable FY24 urban or rural statewide average outpatient cost-
to-charge ratio adopted by the medicare program pursuant to the federal rule
referenced in paragraph (A)(10)(b) of this rule (the Ohio average cost-to-
charge ratio will be used for hospitals outside the United States).
(6) Reimbursement for outpatient
services provided by "new hospitals" as defined in
42 C.F.R.
412.300(b) as published in
the October 1, 2023 Code of Federal Regulations shall be calculated
in the same manner as provided under paragraph (A)(5) of this rule.
(7) For purposes of this rule, hospitals are
to report the applicable outpatient revenue codes for accommodation and
ancillary services set forth in table 7 of the appendix to this rule.
(8) For purposes of this rule, coverage
status for designated hospital outpatient services is set forth in table
9 of the
appendix to this rule.
(9)
For purposes of this rule, services subject to always
and sometimes therapy editing are set forth in table 10 of the appendix to this
rule.
(10) For purposes of
this rule, the "applicable medicare reimbursement rate for the hospital
outpatient service under the medicare outpatient prospective payment system "
and the "medicare outpatient prospective payment system " will be determined in
accordance with the medicare program established under Title XVIII of the
Social Security Act, 79 Stat. 286 (1965),
42 U.S.C.
1395 to
1395lll as amended, as of the
effective date of this rule, as implemented by the following materials, which
are incorporated by reference:
(a) 42 C.F.R.
Part 419 as published in the October 1, 2023 Code of
Federal Regulations;
(b) Department
of health and human services, centers for medicare and medicaid services' "42
CFR Parts 405, 410, 416,
419, 424, 485 ,
488, 489 Medicare Program: Hospital Outpatient Prospective Payment and
Ambulatory Surgical Center Payment Systems ; Quality
Reporting Programs; Payment
for Intensive Outpatient
Services in Hospital Outpatient Departments, Community Mental Health Centers,
Rural Health Clinics, Federally Qualified Health Centers, and Opioid Treatment
Programs;
Hospital Price
Transparency; Changes to Community Mental Health Centers Conditions of
Participation, Proposed Changes to the Inpatient Prospective Payment System
Medicare Code Editor; Rural Emergency Hospital Conditions of Participation
Technical Correction" final rule 88 Fed. Reg.
81540 -
82185
(2023).
(c)
The department of health and human services, centers for medicare and medicaid
services' hospital-specific cost-to-charge ratio information as of the October
2023
update to the department of health and human services, centers for medicare and
medicaid services' outpatient-provider specific file (OPSF).
(B) QHP or
self-insuring employer (non-QHP):
A QHP or self-insuring employer may reimburse hospital
outpatient services at:
(1) The
applicable rate under the methodology set forth in paragraph (A) of this rule;
or
(a) For hospitals the department of health
and human services, centers for medicare and medicaid services maintains
hospital-specific cost- to-charge ratio information on, the hospital's
allowable billed charges multiplied by the hospital's cost-to-charge ratio
information referenced in paragraph (A)(10)(c) of this rule multiplied by a
payment adjustment factor of
1.16, not to exceed sixty per
cent of the hospital's allowed billed charges.
(b) For hospitals the department of health
and human services, centers for medicare and medicaid services does not
maintain hospital-specific cost- to-charge ratio information on the hospital's
allowable billed charges multiplied by the applicable
FY24
urban or rural statewide average outpatient cost-to-charge ratio adopted by the
medicare program pursuant to the federal rule referenced in paragraph
(A)(10)(b) of this rule (the Ohio average cost-to-charge ratio will be used for
hospitals outside the United States) multiplied by a payment adjustment factor
of 1.16, not to exceed sixty per
cent of the hospital's allowed billed charges; or
(2) The rate negotiated between the hospital
and the QHP or self-insuring employer in accordance with rule
4123-6-46 of the Administrative
Code.
(C) Provider-based
status
The bureau may request information from any facility billing
the bureau for services as a provider-based facility as may be necessary to
establish whether the facility meets the criteria for provider-based status
under 42 C.F.R.
413.65 as published in the October 1,
2023 Code
of Federal Regulations. The information requested may include an attestation by
the facility.
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